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Request for a Release of Information

This is not a Release of Information. This is a request to our office to provide you with a Release of Information.

Please fill out the following form, and our office will generate a Release of Information for you and send it to your through our HIPPA compliant messaging system, KLARA, within two business days. Once you have received this Release of Information, you must review it, initial it and sign it where appropriate, and send it back to our office through KLARA. We will then fax out your request to the appropriate individual or office.

Patient Name *
Patient Name
Are you requesting information to be sent to Dr. Shiekh or for Dr. Shiekh to send out information? *
Who can receive / use the health information? *
Who can receive / use the health information?
Address for Individual or Entity that you are requesting information to or from *
Address for Individual or Entity that you are requesting information to or from
What information can be disclosed?
What information can be disclosed?